Hospitals are dropping Medicare Advantage left and right

Investing Strategies Retirement Investing
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{{ Medicare Advantage provides health coverage to more than half of the nation’s seniors, but a growing number of hospitals and health systems nationwide are pushing back and dropping the private plans altogether.

Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

"It’s become a game of delay, deny and not pay,‘’ Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.” }}

Hospitals are dropping Medicare Advantage left and right (beckershospitalreview.com)

It’s interesting that Scripps Health doesn’t even want to see Medicare Advantage patients on an “out-of-network” basis, which presumably would be more profitable. {{ LOL }}

intercst

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When push comes to shove, what happens? We learn to rein in health care costs? Insurance becomes very expensive? We come up with more resources? Or more people are excluded from our “universal” health care system?

Take your pick. Which do you choose? I think politicians see this as a hot button and are likely to look for a workable solution.

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Perhaps the solution to this problem is to actually implement a “universal” health care system in the United States.

Of course this would require an increase in income taxes and years to build out the needed infrastructure.

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We’re currently paying twice as much as other large industrialized countries for a health care system that kills us 3 years sooner than our peers. Should we be paying three times as much for a crappier health system? I don’t think we’re lacking for health care spending. We do have two problems that I see.

  1. An unbelieveable amount of large scale, for-profit, fraud and corruption in health care brought about by health insurers and Private Equity in cooperation with a “bought & paid for” Congress. The most recent example is this change to Medicare & Medicaid payment rules that allows Private Equity to essentially impose a 2.9% credit card fee on every payment that goes to a doctor or hospital. Think about it – 2.9% on $1.5 Trillion in Medicare & Medicaid spending is $44 Billion/year siphoned-off to the worst people in America. And that’s just the most recent “tip of the iceberg”.

The Hidden Fee Costing Doctors Millions Every Year — ProPublica

  1. the most racist, ignorant and innumerate 35% of the population that doesn’t want blacks & Hispanics to get health care. The health insurers and Private Equity have been very successful in energizing this group by crying “socialism” whenever someone starts looking to rein in the financial fraud in the health care system. Does that 35% actually understand that they’re paying twice as much for health care and that their rural hospitals are closing under the burden of the fraud? It would require an understanding of arithmetic that may well be beyond them. We’ll just have to wait until the entire system collapses, and then blame it on Obama.

intercst

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If the funds now paid to insurance companies were diverted to a universal health care plan, i wonder how much additional tax would be required.

In fact a plan could be devised with tiers to do exactly that. Basic coverage with funds available then with fees for additional levels of coverage.

Of course Congress will mess with the plan and add their pet coverages increasing costs and requiring additional funds. And insurance companies and vested interests will oppose strongly at every opportunity.

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I don’t think we need any additional taxes. Just enforce transparency and competitive pricing across all aspects of health care. We’re paying twice as much as other industrialized countries – and most of the excess cost is simple price gouging.

intercst

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Here’s an example of drug price gouging. Dad takes Celecoxib. He was buying from his doctor a 100-count bottle for $16.50. He went into an assisted living home. They use a local pharmacy for the resident’s medicines. The Celcoxib was $104.00 for a 30-day supply. That’s 21 times higher. His other meds were double to triple higher than what he was paying.

We have the option to purchase his drugs separately. At that price difference we will.

We told them we would start supplying

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I personally experienced a part of this problem. I had a coronary procedure for which medicare paid the hospital just over $23,000 when a previous $2,000 test plus consideration of symptoms showed I had virtually no coronary occlusion.

The sequence -

#1. New PCP doc wanted a second coronary calcium scan. My first scan 4 year previous showed enough calcium, the statistical average has some coronary artery disease. Another consideration was to measure rate of calcium buildup change. I have had high cholesterol since before statin drugs existed.

#2. Cardiologist said need to get measure if your heart can get adequate blood - nuclear stress test. (Note - I have never experienced any chest pain and I do exercise regularly on treadmills plus brisk outdoor walks.)

#3. Results the same as 4 year earlier - some indication of occlusion, but no angina. If the exact scans of this test were compared to the earlier one, no differences would have been found.

#4. PCP says in her experience when people get this result, virtually all cardiologists go for an angiogram.

#5. Cardiologist recommends, but significantly does not say “should” or “need” a CT angiogram. This specific test shows results that are consistent with an 60% to 80% occlusion of one artery and significant occlusion in another.

This got my attention! The cardiologist says arterial angiogram – open an artery up, run a wire into the heart and look blood flow of the suspect arteries. The cardiologist does state, all we really know for sure is I have significant amounts of calcium associated with my arteries. That a calcium could be inside on the walls occluding blood flow. It could be on the exterior or the coronary artery. It could even be within the artery wall.

#6. On July 3rd at 5:30am, I am prepped. My procedure is delayed 45 minutes - somebody had just arrived at the ER undergoing a heart attach and opening his arteries was more important than just checking mine out.

8:30am – I am out the door having been told my arteries are great - I have one 10% occlusion and that is abnormally good for an 81 year old male.

The key connections that were not made:

#1. Despite exercise to heart rates at 80% of my “max heart rate” I had never experienced any chest pain. (True I could have ignored discomfort or actually failed to admit pain.)

#2. Both nuclear stress tests showed the exact same result -a minor blood insufficiency and NO CHANGE in the apparent coronary blood flow insufficiency when exercising on the treadmill.

When my PCP and I went through all this history and actual test results, it was clear to both of us, that $23,000 arterial angiogram was a waste of money.

A totally unrelated event lead to an abdominal CT scan and among the radiologist’s notes was an aortic aneurysm. Since this is not close to the size where surgery is needed, my PCP and I will be looking long and hard before surgery is even considered.

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Reading through your sequence of referral to a specialist and a specialist recommending a course of action - it doesn’t sound like this would have necessarily been different in a country with a different health system. The question is - would the payor in that system been charged the $23k, or less. My guess is significantly less.

AJ

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To be sure. Not too far from a reasonable standard of care in most any country where heart disease is still the #1 killer and when folk do have a history of risk factors. I wouldn’t personally consider a catheterization procedure that was able to say definitively that I was actually healthier than I imagined to have been a waste of money…neither would my PCP, I imagine. I triggered a similar series of events about 18 months ago, minus the catheterization and any sign of compromised blood flow on nuclear stress test (probably why my cardiologist didn’t recommend the cath procedure)

As to the cost in other countries … a definite “maybe” there. At least as far as those with a single payer system like England’s NHS, which is the only other country I have actual experience of. Such a thing as “Explanation of Benefits” forms don’t exist…and neither does the sector of the workforce that generates such paperwork. The coders and billers on the provider side and the claims processors on the insurance company side. All of whom receive a compensation package from the US healthcare dollar. I have no idea of the number of folk involved in this but I suspect the sum total of all their paychecks is going to be close to what all those CEOs etc receive from all the “skim”?

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Not sure why you think it’s a “maybe”. The US spends far more than any other developed country How does health spending in the U.S. compare to other countries? - Peterson-KFF Health System Tracker both per capita:

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and as a percent of GDP:

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AJ

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Oh, for sure about the total spending but the “maybe” was due to the fact that, without an EoB or any other sort of line-item accounting, there’s no way to be absolutely sure that it’s just due to the cost of individual procedures or stuff that’s obviously related to clinical care in any identifiable way.

The amount of money that’s spent on simply getting payment here in the US is, in all likelihood, an unexpected contributor to the costs of doing business (and ultimately cost to the consumer/society at large) that wouldn’t show up on the “comparable country average”

Shortly after we came to the US (my husband’s a physician and I’m a dentist…retired now) there was an attempt to control ER costs/cut down on friviolous usage in the UK by introducing a nominal charge at time of service. Not the first departure from the original tenets of the NHS and not enough to actually pay for care but, rather, to have patients perceive that they have some skin in the game…and maybe think twice before showing up with a non-emergency. It was abandoned pretty quickly as the practicalities of implementing it actually cost more than the revenue it generated.

FWIW, I haven’t a clue what a traditional angiogram ought to cost because I have no idea of the costs of providing the procedure…or even a step by step “how to” of what happens from start to finish.